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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336425633
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:52:43 PM

Document Has Been Signed on 06/15/2023 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:NELSON ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
336425633
ADMINISTRATOR:ALAN ALIAN JR.FACILITY TYPE:
735
ADDRESS:2216 FIELDING RD.TELEPHONE:
(951) 224-9068
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 5DATE:
06/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lead Staff Charmaine EstigoyTIME COMPLETED:
03:15 PM
NARRATIVE
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On 6/15/2023 at 2:00 p.m. Licensing Program Analyst (LPA) Janette Romero conducted an unannounced health and safety visit to the facility. LPA met with Lead Staff Charmaine Estigoy who was informed of the purpose of the visit.

At the time of the visit there were (4) staff and (5) clients present, and (1) clients at day program. Staff present possessed a cleared background check and were associated to the facility. LPA conducted a tour of the facility's interior and exterior. LPA observed the staff room, clients rooms, bathrooms, outdoor yard/patio, kitchen and dining areas. LPA observed clients in their rooms and common areas.

LPA observed the facility did not meet the requirement to maintain a minimum of two day supply of perishable foods for the amount of clients residing in the home. As a result, a deficiency was issued to the facility. Lead Staff Estigoy stated the facility's administrator provides groceries on, "Fridays, Saturdays or Sundays around 6:00 p.m." Non-perishable foods met Departmental requirements for 7-day supply.

An exit interview was conducted, this report was discussed with Lead Staff Estigoy and a copy of this report was provided to the facility along with an LIC809-D and Appeals Rights.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/15/2023 02:52 PM - It Cannot Be Edited


Created By: Janette Romero On 06/15/2023 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NELSON ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 336425633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2023
Section Cited
CCR
85076(d)(1)

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(d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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Facility stated they will provide a two day supply of perishable foods and maintain required food supply on the premises moving forward. Proof of correction will be provided to CCLD by close of business on 6/16/2023.
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Based on observation and interview, the facility did not meet the requirements to maintain a minimum of a two day supply of perishable foods on the premises. This poses a potential health or safety risk to the clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023


LIC809 (FAS) - (06/04)
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